Laserfiche WebLink
APPLICATION FOR PERUIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County,Public Health Services. <br /> Job Address /10-410 tyoCity Lot Size/Acreage <br /> Owner's Name e Address ' Phone-3 � G S <br /> Contractor E1II� C120S- Address /.5O1 I' a License No,773,?S Phone 3 3v T ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5e DESTRUCTION P;jput of Service Well 0 <br /> PUMP INSTALLATION W. SYSTEM REPAIR ❑ OTHER © Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �.�� SEINER.LINES DISPOSAL FLDI PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .�.. <br /> INTENDED USE TYPE OF WELL PROBLEM:AREA, CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation�� Dia. of Well Casing <br /> %I'nomestic/Private 'WGravel,Pack ❑ Tracy Type of Casing wC Specifications �gqr-y�D <br /> I'1 Public 25s� 11-1 Other fl Delta /Depth of Grout Seal lO�j Type of Grout_ l ���4'j <br /> I I Irrigation '�SS2 Approx. Depth I 1 Eastern Surface Seal Installed by W n' <br /> Repair Work Done U Type of Pump S !2,4 f3' H,P. _ 1 _ State Work Done `LTA <br /> Well Destruction �C Weli Diameter _ Sealing Material A Depth lam" �` y,,�> � <br /> Depth _ Filler Material i Depth Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No ieptic system permitted it public sewer is 03 <br /> available within 200 feet.1 <br /> Installation will serve: Residence_ Commercial_ Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments y <br /> PKG. TREATMEgT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line A_ <br /> LEACHING LINE.- ❑ No. 8 Length of lines Total length/size -- <br /> FILTER BED 4❑ Distance to nearest. Well FoundationProperty Line <br /> w � r <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: _.Well Foundation Property Line a <br /> DISPOSAL PONDS ❑ o <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for I required inspection. Complete drawing,on reverse side. <br /> Signed Title: 0 L­/l�-'49 \pate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dais ' �3 Area L F <br /> Pit or rou napection by %veDate �ttfdq,3 Final Inspection Jby WIJ� DauIF <br /> Additional Comments: -f , lab, { l� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 4 <br /> INFE AMOUNT OtJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'9NO..{ <br /> . EN tiltlltEV.tiP46Y L �� ' r/s' OIt <br /> Err u•ss b Zti <br /> u g ,� p220 <br />